Quality Improvement Story Board

Improving Access to Prenatal Care in the First Trimester

Project coordinated by Kansas Health Institute, Kansas Association of Local Health Departments, Kansas Department of Heath and Environment, and KUMC Area Health Education Centers

Act Plan

DoStudy

QI Team Members:MLC-3 in Kansas

1. Background The Lower 8 of

Southeast Kansas collaborated to address barriers to early prenatal care. We had noticed that young women were not receiving prenatal care during the fi rst trimester of their pregnancy.

Statistical information was downloaded from KDHE/KIC (Kansas Information for Communities) to determine if this was true of all age groups or if there was a specifi c age which needed to be addressed. The 15–24 year age group was more likely to receive inadequate prenatal care. Between 2003–2007, 35 percent of women in this age group did not receive prenatal care in the fi rst trimester. There were 77 births which received no prenatal care.

After reviewing data and collecting anecdot- al information, it was decided that a lack of insurance was the most likely contributing factor. The application process for Medicaid/ CHIP seemed to be the bottleneck.

2. Aim Statement By Dec. 31, 2009, we will promote an

increase of 2 percent in the enrollment of eligible pregnant women in the Medicaid/ CHIP program during the fi rst trimester of pregnancy over the previous quarter’s Women, Infants and Children (WIC) data. Assistance in completing the application and faxing the application to the Kansas Health Policy Authority will be offered to all eligible women.

3. Examine the Current Approach Current practices and processes revealed: ● Lack of a uniform approach within a

public health region. ● Need for educational information. ● Need for comprehensive Maternal and

Child Health (MCH) services. ● Need for Medicaid/CHIP application

assistance.

4. Identify Potential Solutions Provide assistance to pregnant women with

the Medicaid/CHIP application process.

5. Develop an Improvement Theory ● Develop a pregnancy testing checklist. ● Standardize pregnancy/history form. ● Make a sample Medicaid/CHIP application. ● Provide training to all staff for the

application process.

6. Test the Theory The region: ● Reviewed best practices and

recommendations for increasing the timeliness of prenatal care.

● Collected WIC data for March–May, 2009 for a measurement baseline.

● There were 69.2% of Medicaid/CHIP women who received fi rst trimester care in this time period.

● Combined the questionnaire and checklist into a one-page document.

● Standardized existing pregnancy/history form.

● Made a sample of the Medicaid/CHIP application.

● Developed a checklist for the health departments’ staff to use.

● Provided training to all staff regarding the utilization of forms and the application process.

● Tested the standardized questionnaire/ checklist in the Lower 8 health departments beginning July 1, 2009.

7. Study the Results Evaluation of implemented intervention took place in October–November 2009 by: ● Review the survey

information collected from WIC clinics of newly pregnant enrollees for the months of July–September. There were 76.6 percent of Medicaid/CHIP women who received fi rst trimester care in this time period, an increase of 10.7 percent.

● Conduct staff meeting to get feedback from all eight health departments on new process.

● Share feedback with Lower 8 MLC-3 team members.

8. Standardize the Improvement ● Continue use of the questionnaire/

checklist to assist in uniformity and continuity.

● Continue to provide assistance with Medicaid/CHIP application process.

9. Establish Future Plans ● Continue to gather WIC data on a semi-

annual basis. ● Analyze data to determine if theory

continues to achieve the desired outcome.

Do

Study

Act

Lower 8 of Southeast Kansas Counties: Chautauqua, Cherokee, Crawford, Elk, Labette, Montgomery, Neosho, and Wilson

Serving a population of: 154,883

● Ruth Bardwell ● Debbi Baugher ● Jeanie Beason ● Kandy Dowell

● Todd Durham ● Betha Elliott ● Janis Goedeke ● Teresa Starr

Plan

0

10

20

30

40

50

60

70

80

First Trimester Prenatal Care Access Among Medicaid/CHIP Beneficiaries

March 2009 – May 2009

July 2009 – Sept. 2009

Intervention

Pr en

at al

C ar

e A

cc es

se d

in

Fi rs

t T ri

m es

te r

(% ) 10.7%

increase 69.2%

76.6%

Lack of a Support System

Financial Resources Physicians

Cultural BarriersEducation Lack of

knowledge of importance of prenatal care

Complex SRS application process

Language Habits

Parental Non-involvement

of boyfriend

Job-related issues (absences from work)Schools

Geography (distance

from provider)

Traditions

Lack of insurance

Embarassed to seek financial

assistance for prenatal care

Lack of hospital

Unable to get appointment

Physicians do not initiate care until second trimester

No provider for prenatal

care in county

Religious beliefs

Attitudes about prenatal care

Fishbone Diagram: Root causes for the lack of timely prenatal care in the Lower 8 of Southeast Kansas Subregion

Barriers to Timely Prenatal Care

Quality Improvement Story Board

Improving Access to Prenatal Care in the First Trimester

Project coordinated by Kansas Health Institute, Kansas Association of Local Health Departments, Kansas Department of Heath and Environment, and KUMC Area Health Education Centers

Act Plan

DoStudy

QI Team Members:MLC-3 in Kansas

1. Background The Northeast Corner Subregion, which

consists of the Shawnee County Health Agency and the Jefferson County Health Department, serves a signifi cant number of women of childbearing age. For the purpose of this project, services provided to women through certain programs will engage consumers by linking them to the health care delivery system through guidelines and provider networking.

2. Aim Statement By Oct. 1, 2009, in

four clinic programs at two local health departments, pregnant women not enrolled in prenatal care will consistently be given a current listing of community obstetricians, 90 percent of those with limited resources will receive staff assistance in making a prenatal intake appointment, and 95 percent of those intakes will be scheduled within 10 working days from the date of request.

3. Examine the Current Approach Current practices and processes:

● Verbal counseling on prenatal care to all pregnant women.

● Not all clinics provide listings of area obstetricians to all pregnant women, or consistently refer pregnant women to prenatal services.

● Limited number of prenatal intake appointments are available each week.

4. Identify Potential Solutions ● Keep both health departments current

on clinic schedules.

● Offer to make intake appointments while clients are still on-site.

● Collect primary data from women of childbearing age through a survey in order to identify common barriers.

5. Develop an Improvement Theory ● Open the clinic intake appointment

book to accommodate two to fi ve more intakes per week.

● Eliminate “cold handoff “ referral of providing written provider contact information only and move to “warm handoff” of making the fi rst prenatal intake appointment.

● Administer a survey tool to identify barriers to prenatal care.

● Reformat intake registration form and change the process of how the form is fi lled out.

6. Test the Theory The team implemented a number of qual-

ity improvement interventions during the course of the project. First, the team focused on accommodating as many new in- take appointments as the clinics’ schedule al- lowed. By opening their scheduling registers and demanding fl exibility, two to fi ve more intake visits per week were scheduled.

Second, the new system made sure that prenatal intake appointments were scheduled on-site.

Third, the focus was on administration of a survey tool to identify reasons why women did not receive timely prenatal care.

7. Study the Results Creation of additional appointment

slots per week resulted in a substantial increase in the number of follow-up appointments scheduled within two weeks of the initial request. Before the scheduling intervention, only 83 percent of appointments were within that timeframe. After the intervention, that rate went up to 97 percent — a 17 percent increase. The intervention also contributed to an increase in the number of women who entered

prenatal care in the fi rst trimester by 35 percent — from 51 percent to 69 percent.

The surveys administered as part of the third intervention showed that two-thirds of the pregnant women at both clinics did not plan their pregnancies, making it harder for them to access prenatal care in a timely fashion after conception.

8. Standardize the Improvement ● Continue to expand the number of

prenatal intake appointments. ● Standardize the process to schedule

prenatal intake appointments within ten working days. ● Adopt reformatted

intake registration form in both English

and Spanish.

9. Establish Future Plans

Form a group to focus on barriers to prenatal care identifi ed by survey respondents.

Northeast Corner Subregion

Counties: Shawnee and Jefferson Serving a population of: 193,130

● Eileen Filbert ● Anne Freeze ● Teresa Fisher ● Kay Powell ● Judy Willett

● Debbie McNary ● Allison Alejos ● Barbara Heston ● Martha Conlin

Plan

Do

Study

Act

0

10

20

30

40

50

60

70

80

Jan. 1, 2008 – Dec. 31, 2008

51%

69%

May 22, 2009 – Aug. 14, 2009

Intervention

Pr en

at al

C ar

e A

cc es

se d

in Fi

rs t T

ri m

es te

r (%

) 35% increase

First Trimester Prenatal Care Access Among Medicaid/CHIP Beneficiaries

People Information/Feedback Machines

Materials/EquipmentMethods/ Procedures

Motivation/Incentives

Scheduling

Appointments more than two

weeks out

Family influence: Lack knowledge of

prenatal care

Lack knowledge of prenatal care

Good resources not available?

What resources are most useful?

Not a patient priority

Community OB’s not invested in 1st trimester

Lack family support

Not easily retrievable

or timelyDecreased potential for miscarriage in 2nd trimester

Not listening to information

What are patients’ resources for information

Lack knowledge No support system at all

Limited pre- natal data

available

No transportationNo money/coverage to pay for care

SRS application process is complex

Don’t seek care until having a problem

Talk themselves out of early care

Have had previous healthy babies

No phone to make appointments

No appropriate educational materials

Patients lack knowledge of prenatal care

In 2008, 49% of women did not access early prenatal care at the SCHA-CHC M&I clinic. 85% were age 20 years or older.

Fishbone Diagram: Root causes for the lack of timely prenatal care in the Northeast Corner Subregion

Completed PDSA Worksheet (NC Program on Health Literacy)

PDSA Directions and Examples

The Plan-Do-Study-Act method is a way to test a change that is implemented. By going through the prescribed four steps, it guides the thinking process into breaking down the task into steps and then evaluating the outcome, improving on it, and testing again. Most of us go through some or all of these steps when we implement change in our lives, and we don’t even think about it. Having them written down often helps people focus and learn more. For more information on the Plan-Do-Study-Act, go to the IHI (Institute for Healthcare Improvement) Web site or this PowerPoint presentation on Model for Improvement. Keep the following in mind when using the PDSA cycles to implement the health literacy tools:

 Single Step – Each PDSA often contains only a segment or single step of the entire tool implementation.

 Short Duration – Each PDSA cycle should be as brief as possible for you to gain knowledge that it is working or not (some can be as short as 1 hour).

 Small Sample Size – A PDSA will likely involve only a portion of the practice (maybe 1 or 2 doctors). Once that feedback is obtained and the process refined, the implementation can be broadened to include the whole practice.

Filling out the worksheet

Tool: Fill in the tool name you are implementing. Step: Fill in the smaller step within that tool you are trying to implement. Cycle: Fill in the cycle number of this PDSA. As you work though a strategy for implementation, you will often go back and adjust something and want to test if the change you made is better or not. Each time you make an adjustment and test it again, you will do another cycle. PLAN I plan to: Here you will write a concise statement of what you plan to do in this testing. This will be much more focused and smaller than the implementation of the tool. It will be a small portion of the implementation of the tool. I hope this produces: Here you can put a measurement or an outcome that you hope to achieve. You may have quantitative data like a certain number of doctors performed teach-back, or qualitative data such as nurses noticed less congestion in the lobby. Steps to execute: Here is where you will write the steps that you are going to take in this cycle. You will want to include the following:

Completed PDSA Worksheet (NC Program on Health Literacy)

 The population you are working with – are you going to study the doctors’ behavior or the patients’ or the nurses’?

 The time limit that you are going to do this study – remember, it does not have to be long, just long enough to get your results. And, you may set a time limit of 1 week but find out after 4 hours that it doesn’t work. You can terminate the cycle at that point because you got your results.

DO After you have your plan, you will execute it or set it in motion. During this implementation, you will be keen to watch what happens once you do this. What did you observe? Here you will write down observations you have during your implementation. This may include how the patients react, how the doctors react, how the nurses react, how it fit in with your system or flow of the patient visit. You will ask, “Did everything go as planned?” “Did I have to modify the plan?” STUDY After implementation you will study the results. What did you learn? Did you meet your measurement goal? Here you will record how well it worked, if you meet your goal. ACT What did you conclude from this cycle? Here you will write what you came away with for this implementation, if it worked or not. And if it did not work, what can you do differently in your next cycle to address that. If it did work, are you ready to spread it across your entire practice?

Examples

Below are 2 examples of how to fill out the PDSA worksheet for 2 different tools, Tool 17: Get Patient Feedback and Tool 5: The Teach-Back Method. Each contain 3 PDSA cycles. Each one has short cycles and works through a different option on how to disseminate the survey to patient (Tool 17: Patient Feedback) and how to introduce teach-back and have providers try it. (Tool 5: The Teach-Back Method).

Completed PDSA Worksheet (NC Program on Health Literacy)

PDSA (plan-do-study-act) worksheet

TOOL: Patient Feedback STEP: Dissemination of surveys CYCLE: 1st Try

PLAN

I plan to: We are going to test a process of giving out satisfaction surveys and getting

them filled out and back to us.

I hope this produces: We hope to get at least 25 completed surveys per week during this

campaign. Steps to execute:

1. We will display the surveys at the checkout desk.

2. The checkout attendant will encourage the patient to fill out a survey and put it in

the box next to the surveys.

3. We will try this for 1 week.

DO

What did you observe?

 We noticed that patients often had other things to attend to at this time, like making

an appointment or paying for services and did not feel they could take on another

task at this time.

 The checkout area can get busy and backed up at times.

 The checkout attendant often remembered to ask the patient if they would like to fill

out a survey.

STUDY

What did you learn? Did you meet your measurement goal?

We only had 8 surveys returned at the end of the week. This process did not work well.

ACT

What did you conclude from this cycle?

Patients did not want to stay to fill out the survey once their visit was over. We need to

give patients a way to fill out the survey when they have time.

We will encourage them to fill it out when they get home and offer a stamped envelope to

mail the survey back to us.

Completed PDSA Worksheet (NC Program on Health Literacy)

PDSA (plan-do-study-act) worksheet

TOOL: Patient Feedback STEP: Dissemination of surveys CYCLE: 2nd Try

PLAN

I plan to: We are going to test a process of giving out satisfaction surveys and getting

them filled out and back to us.

I hope this produces: We hope to get at least 25 completed surveys per week during this

campaign. Steps to execute:

1. We will display the surveys at the checkout desk.

2. The checkout attendant will encourage the patient to take a survey and an envelope.

They will be asked to fill the survey out at home and mail it back to us.

3. We will try this for 2 weeks.

DO

What did you observe?

 The checkout attendant successfully worked the request of the survey into the

checkout procedure.

 We noticed that the patient had other papers to manage at this time as well.

 Per Checkout attendant only about 30% actually took a survey and envelope.

STUDY

What did you learn? Did you meet your measurement goal?

We only had 3 surveys returned at the end of 2 weeks. This process did not work well.